Provider Demographics
NPI:1578589503
Name:CHARLES H. DICKERSON
Entity Type:Organization
Organization Name:CHARLES H. DICKERSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:H
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RADIOLOGIC TECHNOLOG
Authorized Official - Phone:903-596-9729
Mailing Address - Street 1:PO BOX 9700
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-2700
Mailing Address - Country:US
Mailing Address - Phone:903-596-9729
Mailing Address - Fax:903-596-7206
Practice Address - Street 1:2208 OLD HENDERSON HWY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-6457
Practice Address - Country:US
Practice Address - Phone:903-596-9729
Practice Address - Fax:903-596-7206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6309261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0860918 01Medicaid
TX459845Medicare PIN